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Alvarez FA, Ardiles V, Chara C, de Santibañes M, Sánchez Clariá R, Pekolj J, de Santibañes E. Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases. Updates Surg 2024; 76:855-868. [PMID: 38647857 DOI: 10.1007/s13304-024-01835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.
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Affiliation(s)
- Fernando A Alvarez
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Victoria Ardiles
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Camila Chara
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Martin de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Rodrigo Sánchez Clariá
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Juan Pekolj
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina.
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Madadi-Sanjani O, Ure BM. Benchmarks for Pediatric Surgical Registries: Recommendations for the Assessment and Grading of Complications. Eur J Pediatr Surg 2024; 34:182-188. [PMID: 37871645 DOI: 10.1055/a-2196-1755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Procedure-related registries in general surgical practice offer a platform for prospective trials, the pooling of data, and detailed outcome analysis. Recommendations by the Idea, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) collaboration and Outcome4Medicine have further improved the uniform reporting of complications and adverse events.In the pediatric surgical network, disease-specific registries for rare and inherited congenital anomalies are gaining importance, fostering international collaborations on studies of low-incidence diseases. However, to date, reporting of complications in the pediatric surgical registries has been inconsistent. Therefore, the European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA) recently endorsed the validation of the first severity grading system for children. The planned reform of the European Paediatric Surgical Audit (EPSA) registry, which includes the implementation of the Clavien-Madadi classification, represents a further effort to establish uniform outcome reporting.This article provides an overview of experiences with surgical registries and complication reporting, along with the potential application of this knowledge to future pediatric surgical practice.
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Affiliation(s)
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Golriz M, Ramouz A, Hammad A, Aminizadeh E, Sabetkish N, Khajeh E, Ghamarnejad O, Carvalho C, Rio-Tinto H, Chang DH, Joao AA, Goncalves G, Mehrabi A. Promising Results of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Perihilar Cholangiocarcinoma in a Systematic Review and Single-Arm Meta-Analysis. Cancers (Basel) 2024; 16:771. [PMID: 38398162 PMCID: PMC10887221 DOI: 10.3390/cancers16040771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND ALPPS popularity is increasing among surgeons worldwide and its indications are expanding to cure patients with primarily unresectable liver tumors. Few reports recommended limitations or even contraindications of ALPPS in perihilar cholangiocarcinoma (phCC). Here, we discuss the results of ALPPS in patients with phCC in a systematic review as well as a pooled data analysis. METHODS MEDLINE and Web of Science databases were systematically searched for relevant literature up to December 2023. All studies reporting ALPPS in the management of phCC were included. A single-arm meta-analysis of proportions was carried out to estimate the overall rate of outcomes. RESULTS After obtaining 207 articles from the primary search, data of 18 studies containing 112 phCC patients were included in our systematic review. Rates of major morbidity and mortality were calculated to be 43% and 22%, respectively. The meta-analysis revealed a PHLF rate of 23%. One-year disease-free survival was 65% and one-year overall survival was 69%. CONCLUSIONS ALPPS provides a good chance of cure for patients with phCC in comparison to alternative treatment options, but at the expense of debatable morbidity and mortality. With refinement of the surgical technique and better perioperative patient management, the results of ALPPS in patients with phCC were improved.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Clinic of General and Visceral Surgery, Diakonie in Südwestfallen, 57076 Siegen, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Carlos Carvalho
- Digestive Oncology Unit, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - Hugo Rio-Tinto
- Department of Radiology, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - De-Hua Chang
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Ana Alagoa Joao
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Gil Goncalves
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
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Lopez-Lopez V, Martínez-Caceres C, Gomez-Valles P, Cruz J, Caballero-Illanes A, Brusadin R, López-Conesa A, Pérez M, Miura K, de la Peña-Moral J, Robles-Campos R. Impact of rapid hypertrophy of tourniquet associating liver partition and portal vein ligation in the tumor progression pathways compared to two stage hepatectomy in patients with colorectal liver metastases. HPB (Oxford) 2023; 25:1235-1246. [PMID: 37407399 DOI: 10.1016/j.hpb.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/22/2023] [Accepted: 06/10/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND It is not known if the inflammatory phenomena related to highly accelerated regeneration activate any signaling pathways that are associated with a major stimulus to colorectal liver metastases (CRLM) disease in tourniquet associating liver partition and portal vein ligation for staged hepatectomy (T-ALPPS) compared to two stage hepatectomy (TSH). METHODS Between January 2012 and April 2018, we prospectively performed biopsies from future liver remnant and deportalized lobe in CRLM patients undergoing T-ALPPS in both stages. Immunohistopathological analysis was performed on the above tissue samples and compared to biopsy samples from patients who underwent TSH for CRLM at our center between September 2000 and August 2011. RESULTS A total of 42 patients (20 TSH and 22 T-ALPPS) were included. There were no differences in the rates of recurrence, overall survival or any of the factors analyzed relating to tumor progression between stages 1 and 2. Regarding the anti-tumor effect, there was a significant reduction in the number of T-CD8 infiltrates in the second stage of TSH (12.5 vs. 5.5, p = 0.02). CONCLUSION The results suggest that liver regeneration with T-ALPPS does not induce higher tumor progression or significant immunological changes in the tumor environment when compared to classical TSH.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Carlos Martínez-Caceres
- Investigation Support Platforms, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Paula Gomez-Valles
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Juan Cruz
- Group of Applied Mathematics in Science and Engineering, Faculty of Computer Science, University of Murcia, C. Campus Universitario, Edificio 32, 30100, Murcia, Spain
| | - Albert Caballero-Illanes
- Department of Pathology, Virgen de La Arrixaca University Hospital, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Asuncion López-Conesa
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - María Pérez
- University of Lleida, Catalonia, Plaça de Víctor Siurana, 1, 25003, Lleida, Spain
| | - Kohei Miura
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain; Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachi-dori, Chuo-ku, Niigata City, 951-8510, Niigata, Japan
| | - Jesús de la Peña-Moral
- Group of Applied Mathematics in Science and Engineering, Faculty of Computer Science, University of Murcia, C. Campus Universitario, Edificio 32, 30100, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain.
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Portal Vein Embolization: Rationale, Techniques, and Outcomes to Maximize Remnant Liver Hypertrophy with a Focus on Contemporary Strategies. Life (Basel) 2023; 13:life13020279. [PMID: 36836638 PMCID: PMC9959051 DOI: 10.3390/life13020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hepatectomy remains the gold standard for curative therapy for patients with limited primary or metastatic hepatic tumors as it offers the best survival rates. In recent years, the indication for partial hepatectomy has evolved away from what will be removed from the patient to the volume and function of the future liver remnant (FLR), i.e., what will remain. With this regard, liver regeneration strategies have become paramount in transforming patients who previously had poor prognoses into ones who, after major hepatic resection with negative margins, have had their risk of post-hepatectomy liver failure minimized. Preoperative portal vein embolization (PVE) via the purposeful occlusion of select portal vein branches to promote contralateral hepatic lobar hypertrophy has become the accepted standard for liver regeneration. Advances in embolic materials, selection of treatment approaches, and PVE with hepatic venous deprivation or concurrent transcatheter arterial embolization/radioembolization are all active areas of research. To date, the optimal combination of embolic material to maximize FLR growth is not yet known. Knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications for PVE, the methods for assessing hepatic lobar hypertrophy, and the possible complications of PVE need to be fully understood before undertaking the procedure. The goal of this article is to discuss the rationale, indications, techniques, and outcomes of PVE before major hepatectomy.
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Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review. Int J Surg 2022; 103:106648. [PMID: 35513249 DOI: 10.1016/j.ijsu.2022.106648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS. METHODS Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software. RESULTS In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear. CONCLUSIONS This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients' quality of life after ALPPS.
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Xing J, Jin B, Zhang B, Du S. Comment on Liver Venous Deprivation or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy?: A Retrospective Multicentric Study. ANNALS OF SURGERY OPEN 2022; 3:e125. [PMID: 37600102 PMCID: PMC10431430 DOI: 10.1097/as9.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jiali Xing
- From the Department of Liver Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College (PUMC) & Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Bao Jin
- From the Department of Liver Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College (PUMC) & Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Baoluhe Zhang
- From the Department of Liver Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College (PUMC) & Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Shunda Du
- From the Department of Liver Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College (PUMC) & Chinese Academy of Medical Sciences (CAMS), Beijing, China
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Very Early Recurrence After Liver Resection for Colorectal Metastases: Incidence, Risk Factors, and Prognostic Impact. J Gastrointest Surg 2022; 26:570-582. [PMID: 34508293 DOI: 10.1007/s11605-021-05123-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver resection for colorectal metastases is affected by a non-negligible recurrence rate. The earlier the recurrence, the worse the prognosis. We analyzed an unexplored topic, i.e., the incidence, predictive factors, and prognostic impact of very early recurrence (≤ 3 months after hepatectomy). METHODS All consecutive liver resections for colorectal metastases performed between 2004 and 2017 were retrospectively reviewed. Inclusion criteria were available recurrence status at 3 months after resection and follow-up ≥ 12 months. RESULTS Overall, 484 patients were analyzed; 56 (11.6%) had very early recurrence. Independent predictors were number of metastases (very early recurrence in 3.7% of patients with solitary metastasis, 8.1% of those with 2-9 metastases; 20.0% of those with 10-14 metastases; 44.4% of those with ≥ 15 metastases, p < 0.001) and extrahepatic disease (very early recurrence in 23.2% of patients with vs. 10.1% of those without extrahepatic disease, p = 0.017). Very early recurrence rate in patients with ≥ 15 metastases and simultaneous extrahepatic disease was 71.4%. Patients with very early recurrence had poor survival (5-year survival 17.3% vs. 44.5% of non-very early recurrence patients, p < 0.001), worse than patients with 3-to-6 months recurrence (p = 0.070), and no different from unresected patients (p = 0.114). Fifteen patients with very early recurrence (26.8%) underwent repeated treatment with adequate survival (at 3 years 42.2%), but seven had a further recurrence within 3 months. CONCLUSIONS Very early recurrence occurs in about 12% of patients undergoing aggressive surgery for colorectal metastases. The risk is increased in patients with numerous metastases or extrahepatic disease. Very early recurrence is associated with very poor prognosis, similar to that of unresected patients, and a low chance of effective repeated treatment.
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Lang H, Baumgart J, Mittler J. Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned? Gut Liver 2021; 14:699-706. [PMID: 32036644 PMCID: PMC7667932 DOI: 10.5009/gnl19233] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/15/2022] Open
Abstract
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Jens Mittler
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastases: review of the literature. Clin Exp Hepatol 2021; 7:125-133. [PMID: 34295978 PMCID: PMC8284168 DOI: 10.5114/ceh.2021.106521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/26/2021] [Indexed: 02/08/2023] Open
Abstract
The liver is considered as one of the most common sites of metastasis and a key determining factor of survival in patients with isolated colorectal liver metastasis (CRLM). For longer survival of patients, surgical resection is the only available option. Especially in CRLM bilobar patients, to achieve R0 resection, maintaining an adequate volume of the future liver remnant (FLR) is the main technical challenge to avoid post-hepatectomy liver failure (PHLF). As standard procedures in the treatment of patients with severe metastatic liver disease, techniques such as portal vein embolization/portal vein ligation (PVE/PVL) accompanied by two-stage hepatectomy (TSH) have been introduced. These methods, however, have drawbacks depending on the severity of the disease and the capacity of the patient to expand the liver remnant. Eventually, implementation of the novel ALPPS technique ignited excitement among the community of hepatobiliary surgeons because ALPPS challenged the idea of unrespectability and extended the limit of liver surgery and it was reported that FLR hypertrophy of up to 80% was induced in a shorter time than PVL or PVE. Nonetheless, ALPPS techniques caused serious concerns due to the associated high morbidity and mortality levels of up to 40% and 15% respectively, and PHLF and bile leak are critical morbidity- and mortality-related factors. Carefully establishing the associated risk factors of ALPPS has opened up a new dimension in the field of ALPPS technique for improved surgical outcome by carefully choosing patients. The benefit of ALPPS technique is enhanced when performed for young patients with very borderline remnant volume. Adopting ALPPS technical modifications such as middle hepatic vein preservation, surgical management of the hepatoduodenal ligament, the anterior approach and partial ALPPS may lead to the improvement of ALPPS surgical performance. Research findings to validate the translatability of ALPPS’ theoretical advantages into real survival benefits are scarce.
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Hepatobiliary scintigraphy and kinetic growth rate predict liver failure after ALPPS: a multi-institutional study. HPB (Oxford) 2020; 22:1420-1428. [PMID: 32057681 DOI: 10.1016/j.hpb.2020.01.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post hepatectomy liver failure (PHLF) after ALPPS has been related to the discrepancy between liver volume and function. Pre-operative hepatobiliary scintigraphy (HBS) can predict post-operative liver function and guide when it is safe to proceed with major hepatectomy. Aim of this study was to evaluate the role of HBS in predicting PHLF after ALPPS, defining a safe cut-off. METHODS A multicenter retrospective study was approved by the ALPPS Registry. All patients selected for ALPPS between 2012 and 2018, were evaluated. Every patient underwent HBS during ALPPS evaluation. PHLF was reported according to ISGLS definition, considering grade B or C as clinically significant. RESULTS 98 patients were included. Thirteen patients experienced PHLF grade B or C (14%) following ALPPS-2. The HBS and the daily gain in volume (KGRFLR) of the future liver remnant (FLR) were significantly lower in PHLF B and C (p = .004 and .041 respectively). ROC curves indicated safe cut-offs of 4.1%/day (AUC = 0.68) for KGRFLR, and of 2.7 %/min/m2 (AUC = 0.75) for HBSFLR. Multivariate analysis confirmed these cut-offs as variables predicting PHLF after ALPPS-2. CONCLUSION Patients presenting a KGRFLR ≤4.1%/day and a HBSFLR ≤2.7%/min/m2 are at high risk of PHLF and their second stage should be re-discussed.
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Schwarz L, Nicol L, Francois A, Mulder P, Faitot F, Dazza M, Bucur P, Savoye-Collet C, Adam R, Vibert E. Major hepatectomy decreased tumor growth in an experimental model of bilobar liver metastasis. HPB (Oxford) 2020; 22:1480-1489. [PMID: 32156510 DOI: 10.1016/j.hpb.2020.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/15/2019] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Two-stage hepatectomy (TSH), is associated with a risk of drop-out due to tumoral progression following portal vein occlusion (PVO). We explored the impact of majorhepatectomy on tumor growth by objective radiological measures comparing to PVO and minor hepatectomy, using a model of bilobar colorectal liver metastasis (CLM). METHODS CLM were induced in 48 BDIX rats by injection of DHDK12-cells. 7 days after cells injection, animals were distributed into 4 groups of equal number (n = 12): portal vein ligation (PVL), sham laparotomy (sham), minor (30%Phx) and major (70%Phx) hepatectomy. MR imaging was used for in vivo analysis of tumor implantation, growth and volumes. RESULTS At POD10, tumour volumes were homogeneously distributed among the 4 groups. Lower TV were significantly observed after 70%Phx comparing to PVL at POD17 (0.63 ± 0.14cm3 vs 0.9 ± 0.16cm3, p = 0.008) and to the 3 others groups at POD24: 1.78 ± 0.38cm3 vs 3.2 ± 0.62cm3 (PVL, p = 0.019), 2.41 ± 0.74cm3 (Sham, p = 0.024) and 2.32 ± 0.59cm3 (30%PHx, p = 0.019). CONCLUSION We confirmed in a reproducible model that contrary to PVO, a major hepatectomy decreases the growth of CLM in the remnant liver. This result leads to questioning the usual TSH and justifies exploring alternative strategies. The "major hepatectomy first-approach" should be an option to be evaluated.
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Affiliation(s)
- Lilian Schwarz
- Rouen University Hospital, Department of Digestive Surgery, 1 Rue de Germont, F-76031, Rouen Cedex, France; Normandie Univ, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, F-76000, Rouen, France.
| | - Lionel Nicol
- Normandie Univ, UNIROUEN, Inserm U1096, FHU- REMOD-VHF, 76000 Rouen, France
| | - Arnaud Francois
- Rouen University Hospital, Department of Pathology, 1 Rue de Germont, F-76031, Rouen Cedex, France
| | - Paul Mulder
- Normandie Univ, UNIROUEN, Inserm U1096, FHU- REMOD-VHF, 76000 Rouen, France
| | - François Faitot
- Strasbourg University Hospital, Hôpital Hautepierre, Department of hepatobiliary and liver transplantation surgery, France
| | - Marie Dazza
- Rouen University Hospital, Department of Digestive Surgery, 1 Rue de Germont, F-76031, Rouen Cedex, France
| | - Petru Bucur
- Tours University Hospital, Department of Digestive Surgery and Liver Transplantation, France
| | - Céline Savoye-Collet
- Rouen University Hospital, Department of Radiology, 1 Rue de Germont, F-76031, Rouen Cedex, France; Normandie Univ, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital, France
| | - René Adam
- Department of Hepatobiliary and Liver Transplantation - Paul Brousse University Hospital, France
| | - Eric Vibert
- Department of Hepatobiliary and Liver Transplantation - Paul Brousse University Hospital, France
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Risk Factors of Positive Resection Margin in Laparoscopic and Open Liver Surgery for Colorectal Liver Metastases. Ann Surg 2020; 275:e213-e221. [DOI: 10.1097/sla.0000000000004077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Liver regeneration and liver metastasis. Semin Cancer Biol 2020; 71:86-97. [PMID: 32532594 DOI: 10.1016/j.semcancer.2020.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
Surgical resection for primary and secondary hepatic neoplasms provides the best chance of cure. Advanced surgical techniques such as portal vein embolisation, two-staged hepatectomy and associated liver partition and portal vein ligation for staged-hepatectomy (ALPPS) have facilitated hepatic resection in patients with previously unresectable, bi-lobar disease. These techniques are frequently employed to ensure favourable clinical outcomes and avoid potentially fatal post-operative complications such as small for size syndrome and post-hepatectomy liver failure. However, they rely on the innate ability of the liver to regenerate. As our knowledge of liver organogenesis, liver regeneration and hepatocarcinogenesis has expanded in recent decades it has come to light that liver regeneration may also drive tumour recurrence. Clinical studies in patients undergoing portal vein embolisation indicate that tumours may progress following the procedure in concordance with liver regeneration and hypertrophy, however overall survival in these patients has not been shown to be worse. In this article, we delve into the mechanisms underlying liver regeneration to better understand the complex ways in which this may affect tumour behaviour and ultimately inform clinical decisions.
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Hernandez-Alejandro R, Ruffolo LI, Alikhanov R, Björnsson B, Torres OJM, Serrablo A. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis. Int J Surg 2020; 82S:103-108. [PMID: 32305531 DOI: 10.1016/j.ijsu.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/24/2022]
Abstract
Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.
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Affiliation(s)
- Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA.
| | - Luis I Ruffolo
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Clinical Research Center of Moscow, Moscow, Russia
| | - Bergthor Björnsson
- Department of Surgery in Linköping, And Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, University Hospital and School of Medicine, Federal University of Maranhão, São Luís, Brazil
| | - Alejandro Serrablo
- Division of Surgery, Miguel Servet University Hospital and University of Zaragoza School of Medicine, Zaragoza, Spain
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16
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Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained both interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of liver failure following major hepatectomy. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE; however, it is also associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time while preserving the extensive FLR hypertrophy. METHODS A search of the PubMed, Medline, EMBASE and Cochrane Library databases was conducted on 10 July 2019. 1231 studies were identified and screened. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were included in the analysis. RESULTS 1088 open and 46 MIS-ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p = 0.028) and comparatively more right extended hepatectomies (p = 0.006) as compared to right hepatectomy and left extended hepatectomy performed. Operative parameters (time and blood loss) did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥ IIIa) following stage 1 (p = 0.063) and significantly lower median mortality (0.00% vs 8.45%) (p = 0.007) compared to open ALPPS. CONCLUSION Although MIS ALPPS would seem to be better than open ALPPS with reduced morbidity and mortality rates, there is still limited evidence on MIS ALPPS. There is a need for a higher quality of evidence on MIS ALPPS vs. open ALPPS to answer whether MIS ALPPS can replace open ALPPS.
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Boda-Heggemann J, Hofheinz R, Gkika E, Brunner T, Krug D. Beyond the scalpel - mortality after liver surgery in patients with liver metastases - time to rethink the indications. Br J Surg 2019; 107:149. [PMID: 31869462 DOI: 10.1002/bjs.11412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 11/11/2022]
Abstract
Comment to Filman et al., Mortality after liver surgery in Germany. Br J Surg, 2019.
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Affiliation(s)
- J Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - R Hofheinz
- Tagestherapiezentrum, Interdisziplinäres Tumorzentrum, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - E Gkika
- Department of Radiation Oncology, University Medical Center Freiburg, Freiburg in Breisgau, Magdeburg, Germany
| | - T Brunner
- Department for Radiation Oncology, University Medical Center Magdeburg, Magdeburg, Germany
| | - D Krug
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Systematic review and meta-analysis of local ablative therapies for resectable colorectal liver metastases. Eur J Surg Oncol 2019; 46:772-781. [PMID: 31862133 DOI: 10.1016/j.ejso.2019.12.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/01/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Local ablative therapies (LAT) have shown positive but heterogenous outcomes in the treatment of colorectal liver metastases (CRLM). The aim of this systematic review is to evaluate LAT and compare them with surgical resection. METHODS In accordance with PRISMA guidelines, Medline, EMBASE, Cochrane and Web of Science databases were searched for reports published before January 2019. We included papers assessing radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CA) and electroporation (IRE) treating resectable CRLM with curative intention. We evaluated LAT related complications and oncological outcomes as tumour progression (LTP), disease-free survival (DFS) and overall survival (OS). RESULTS The literature search yielded 6767 records; 20 papers (860 patients) were included. No included studies related mortality with LAT. Median adverse events percentage was 7%: (8% RFA;7% MWA). Median 3y-DFS was 32% (24% RFA; 60% MWA); 5y-DFS was 27%: (18% RFA; 38.5% MWA). Median 3y-OS was 59% (60% RFA; 70% MWA; 34% CA), 5y-OS was 44.5% (43% RFA; 55% MWA; 20% CA). Surgical resection showed decreased LTP, improved DFS and OS than those reported with LAT, with RFA accounting for reduced 1y-DFS (RR 0.83, 95%CI 0.71-0.98), 3y-DFS (RR 0.5, 95%CI 0.33-0.76), 5y-DFS (RR 0.53, 95%CI 0.28-0.98) and 5y-OS (RR 0.76, 95%CI 0.58-0.98) in comparison with surgical resection. CONCLUSIONS Low quality evidence suggests that both RFA and MWA seem superior to CA. MWA presents similar adverse events when compared to RFA with a possible increase in DFS and OS. Surgical resection still seems to provide superior DFS and OS in comparison with LAT.
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Two-Stage Hepatectomy and ALPPS for Advanced Bilateral Liver Metastases: a Tailored Approach Balancing Risk and Outcome. J Gastrointest Surg 2019; 23:2391-2400. [PMID: 30820795 DOI: 10.1007/s11605-019-04145-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Two-stage hepatectomy (TSH) with or without portal vein ligation (PVL) or portal vein embolization (PVE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) are surgical strategies in the treatment of advanced colorectal liver metastases (CRLM). The role of each strategy is yet ill defined. The aim of this analysis is to share our center experience with conventional TSH with or without PVL/PVE and ALPPS in patients with advanced bilateral CRLM. PATIENTS AND METHODS Data were extracted from a prospectively collected institutional database. Complication rates according to the Dindo-Clavien classification, overall and recurrence-free survival data were analyzed. RESULTS Between 2008 and 2017, 790 liver resections were performed in 611 patients with CRLM. Out of 320 patients with bilateral disease, TSH (as right or extended right hepatectomy) with or without PVL/PVE was performed in 50 patients and ALPPS in 8. Stage 2 was completed in 36 (72%) out of 50 TSH/PVL/PVE and in all ALPPS patients (100%). Median follow-up was 15.8 months (0.9 to 111.9 months). On an intention-to-treat basis, the median overall survival was 26.7 (21.8-35.1 range) months after TSH/PVL/PVE and 36.2 months (11.3-61.2 range) after ALPPS (p = 0.809). In the TSH/PVL/PVE cohort, the median overall survival was 29.9 (19.0-40.3) months in patients who completed stage 2 compared to 13.8 months in patients who did not (p < 0.001). Disease recurred in 60% in the TSH/PVL/PVE cohort and in 87.5% in the ALPPS cohort (p = 0.777). The median recurrence-free survival was 5.9 (1.7-18.6) months after TSH/PVL/PVE and 3 (1.6-14.8) months after ALPPS (p = 0.680). CONCLUSION The treatment of advanced bilateral CRLM remains a surgical and oncological challenge. A tailored approach to bilateral CRLM uses TSH/PVL/PVE as first and ALPPS as second rescue treatment in order to achieve resectability in patients with extensive tumor burden not amenable to one-stage resection. ALPPS should be reserved for patients with no other surgical options.
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Au KP, Chan ACY. Current status of associating liver partition with portal vein ligation for staged hepatectomy: Comparison with two-stage hepatectomy and strategies for better outcomes. World J Gastroenterol 2019; 25:6373-6385. [PMID: 31798275 PMCID: PMC6881507 DOI: 10.3748/wjg.v25.i43.6373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Since its introduction in 2012, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has significantly expanded the pool of candidates for liver resection. It offers patients with insufficient liver function a chance of a cure. ALPPS is most controversial when its high morbidity and mortality is concerned. Operative mortality is usually a result of post-hepatectomy liver failure and can be minimized with careful patient selection. Elderly patients have limited reserve for tolerating the demanding operation. Patients with colorectal liver metastasis have normal liver and are ideal candidates. ALPPS for cholangiocarcinoma is technically challenging and associated with fair outcomes. Patients with hepatocellular carcinoma have chronic liver disease and limited parenchymal hypertrophy. However, in selected patients with limited hepatic fibrosis satisfactory outcomes have been produced. During the inter-stage period, serum bilirubin and creatinine level and presence of surgical complication predict mortality after stage II. Kinetic growth rate and hepatobiliary scintigraphy also guide the decision whether to postpone or omit stage II surgery. The outcomes of ALPPS have been improved by a combination of technical modifications. In patients with challenging anatomy, partial ALPPS potentially reduces morbidity, but remnant hypertrophy may compare unfavorably to a complete split. When compared to conventional two-stage hepatectomy with portal vein embolization or portal vein ligation, ALPPS offers a higher resection rate for colorectal liver metastasis without increased morbidity or mortality. While ALPPS has obvious theoretical oncological advantages over two-stage hepatectomy, the long-term outcomes are yet to be determined.
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Affiliation(s)
- Kin Pan Au
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Albert Chi Yan Chan
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
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21
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany.
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22
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Melandro F, Giovanardi F, Hassan R, Larghi Laureiro Z, Ferri F, Rossi M, Mennini G, Pawlik TM, Lai Q. Minimally Invasive Approach in the Setting of ALPPS Procedure: a Systematic Review of the Literature. J Gastrointest Surg 2019; 23:1917-1924. [PMID: 31197682 DOI: 10.1007/s11605-018-04092-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/20/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a new surgical technique for the resection of advanced hepatic malignancies with predicted insufficient future liver remnant. In some patients, ALPPS can be associated with an increased risk of poor outcomes. Minimally invasive surgery (MIS) has been proposed in combination with ALPPS with the intent to minimize this risk. We systematically evaluated the outcomes of MIS-ALPPS cases to compare the relative outcomes of open ALPPS versus MIS-ALPPS. METHODS A systematic review was done in accordance with the PRISMA guidelines. Search terms utilized included the following: ("ALPPS"[Title/Abstract] OR "associating liver partition and portal vein ligation for staged hepatectomy"[Title/Abstract] OR "in situ split"[Title/Abstract]) AND ("minimally invasive"[Title/Abstract] OR "laparoscopic"[Title/Abstract] OR "robotic"[Title/Abstract]). RESULTS Fifteen articles were identified, with a total of 27 patients reported. Colorectal metastatic disease was the most commonly observed indication for MIS-ALPPS (66.7%), followed by hepatocellular carcinoma (25.9%). Time passed from the first to the second stage ranged 7-30 days. MIS-ALPPS patients did not experience procedure failures between the first and second stages. Only four (15.4%) subjects had a grade IIIb complication. No perioperative mortality after the first or second stage was reported. Compared with open ALPPS, MIS-ALPPS demonstrated better results. Hospital stay duration ranged 8-33 days with a follow-up ranging 1-20 months. CONCLUSIONS MIS-ALPPS appears to be safe, with potentially lower morbidities and mortalities relative to open patients. The present results should be considered with caution. A limited number of articles exist on this topic. Furthermore, selection biases exist when comparing open versus MIS-ALPPS data. Registry studies are needed to better define the outcomes of patients undergoing MIS-ALPPS.
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Affiliation(s)
- Fabio Melandro
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Francesco Giovanardi
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Redan Hassan
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Zoe Larghi Laureiro
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Flaminia Ferri
- Division of Gastroenterology, Department of Clinical Medicine, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Gianluca Mennini
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Timothy M Pawlik
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Quirino Lai
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy. .,Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
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Yang X, Yang C, Qiu Y, Shen S, Kong J, Wang W. A preliminary study of associating liver partition and portal vein ligation for staged hepatectomy in a rat model of liver cirrhosis. Exp Ther Med 2019; 18:1203-1211. [PMID: 31316615 PMCID: PMC6601136 DOI: 10.3892/etm.2019.7688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 04/12/2019] [Indexed: 02/05/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a rat model of liver cirrhosis has not, to the best of our knowledge, been previously investigated. The present study therefore aimed to establish a model of ALPPS in cirrhotic rats and to assess liver regeneration. Rats were randomly divided into an ALPPS group with carbon tetrachloride-induced cirrhosis (group A) and a normal liver (group B). Rat weight, cytokine levels, biochemical parameters and histopathology were assessed 1, 2, 3, 7 and 14 days after ALPPS. Higher aspartate aminotransferase and alanine aminotransferase levels were detected in group A on the first postoperative day. On the first, second and third days, hepatocyte proliferation rate was higher in group B than in group A. After 3 days, hepatocyte proliferation rate in group B began to decrease, but the rate in group A continued to increase until the 14th day. Higher levels of hepatocyte growth factor, interleukin-6 and tumor necrosis factor-α were detected in group A compared with group B, but the differences were not significant. The present study demonstrated that ALPPS promoted liver regeneration in a rat model of cirrhosis, but significantly impaired liver function. Compared with the ALPPS model, group B exhibited a delayed peak of proliferation. The mechanism of liver regeneration induced by ALPPS in cirrhotic rats may be associated with increased cytokine levels.
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Affiliation(s)
- Xianwei Yang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Chuang Yang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China.,Department of Hepatobiliary and Pancreatic Surgery, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan 621000, P.R. China
| | - Yiwen Qiu
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Shu Shen
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Junjie Kong
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Wentao Wang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
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Xiang F, Hu ZM. Chance and challenge of associating liver partition and portal vein ligation for staged hepatectomy. Hepatobiliary Pancreat Dis Int 2019; 18:214-222. [PMID: 31056484 DOI: 10.1016/j.hbpd.2019.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 04/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was first performed in 2007. The critical patient selection, timing to perform the second stage operation, and minimally invasive technique are three key factors for patient outcomes. The aim of this review is to summarize published data on these three aspects. DATA SOURCES Studies were identified by searching PubMed for articles published from January 2007 to October 2018, using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" or "ALPPS" or "in situ split". Studies on colorectal liver metastasis (CRLM), perihilar cholangiocarcinoma (PHC), and hepatocellular carcinoma (HCC) indicated for ALPPS, cutoff values to determine the timing of stage 2, as well as modifications of ALPPS were included. RESULTS The mortality of ALPPS for CRLM is declining, for PHC is high. In patients with HCC, essential hypertrophy makes the ALPPS safer. However, the degrees of fibrosis affect the hypertrophy. The future liver remnant volume is still the gold standard to start the second stage. Hepatobiliary scintigraphy plays an important role in quantitatively assessing liver function, whereas cutoff values need to be further calibrated. Less-invasive ALPPS modifications have increased and led to a decreased mortality. CONCLUSIONS ALLPS improved the CRLM outcomes; ALPPS is feasible in patients with PHC after failure of portal vein embolization; ALPPS may be an option for HCC patients with major vascular invasion and thrombosis. The simplified and less-invasive ALPPS is the trend.
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Affiliation(s)
- Fei Xiang
- Department of General Surgery, Jiangning Hospital of Nanjing Medical University, Nanjing 211100, China; Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China.
| | - Ze-Min Hu
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China
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25
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Linecker M, Kuemmerli C, Clavien PA, Petrowsky H. Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy. J Surg Oncol 2019; 119:604-612. [PMID: 30847941 DOI: 10.1002/jso.25435] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
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Yamazaki S, Takayama T. Current topics in liver surgery. Ann Gastroenterol Surg 2019; 3:146-159. [PMID: 30923784 PMCID: PMC6422805 DOI: 10.1002/ags3.12233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023] Open
Abstract
Liver resection is one of the main treatment strategies for liver malignancies. Mortality and morbidity of liver surgery has improved significantly with progress in selection criteria, development of operative procedures and improvements in perioperative management. Safe liver resection has thus become more available worldwide. We have identified four current topics related to liver resection (anatomical liver resection, laparoscopic liver resection, staged liver resection and chemotherapy-induced liver injury). The balance between treatment effect and patient safety needs to be considered when planning liver resection. Progress in this area has been rapid thanks to the efforts of many surgeons, and outcomes have improved significantly as a result. These topics remain to be solved and more robust evidence is needed. Precise selection of the optimal procedure and risk evaluation should be standardized with further development of each topic. The present article reviews these four current topics with a focus on safety and efficacy in recent series.
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Affiliation(s)
- Shintaro Yamazaki
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
| | - Tadatoshi Takayama
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
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